Revision 18-2; Effective April 1, 2018

 

 

C—1110 Medical Information

Revision 05-1; Effective January 1, 2005

 

 

C—1111 State Medicaid Agencies

Revision 13-3; Effective July 1, 2013

 

Medical Programs

For links to all State Medicaid Agencies, go to https://www.medicaid.gov/medicaid/by-state/by-state.html.

 

C—1112 Services Under the Texas Medical Assistance Program

Revision 13-3; Effective July 1, 2013

 

Medical Programs

Benefits provided through health insuring agent:

  • In-patient hospital services*
  • Out-patient hospital services*
  • Laboratory and x-ray services
  • Physician's services
  • Podiatrist's services
  • Optometric services*
  • Ambulance services*
  • Family planning services*
  • Home health services limited to nurse and home health aide visits*
  • Medicare Part A deductible and coinsurance when benefits would otherwise be payable under Medical Assistance and Medicare Part B deductible and coinsurance for assigned claims only
  • Chiropractic treatment — limited to Medicare Part B deductible and coinsurance for assigned claims only
  • Eyeglasses*
  • Rural health clinics*

Services provided through contract or by direct vendor payments from the Health and Human Services Commission (HHSC):

  • Nursing care skilled and intermediate care. Skilled care is limited to recipients age 21 and over. Medicare SNF coinsurance.*
  • Active treatment for recipients/patients of any age in licensed and approved section of institutions for individuals with intellectual disabilities.*
  • In-patient hospital care for recipients/patients age 65 and older in contracted mental hospitals and state (tuberculosis) hospitals.*
  • Texas Health Steps (THSteps) screening program and limited dental treatment for eligible individuals under age 21.
  • Prescriptions limited to no more than three covered per month if over 18. Unlimited if 18 and under.
  • Prior authorized hearing aid services.*
  • Primary home care for recipients age 18 and over.*
  • Other medical transportation.

*With limitations — see appropriate provider manuals for details.

The benefits of this program do not extend to:

  • Inmates in a public institution. (Recipients in approved medical units in certain contracted institutions are eligible for vendor payments made by HHSC.)
  • Special shoes or other supportive devices for the feet or walking aids.
  • Services in military medical facilities, Veteran's Administration (VA) facilities, or United States Public Health Service Hospitals.
  • Care and treatment related to any condition for which benefits are provided or are available under Workman's Compensation laws.
  • Dental care and services except certain oral surgery or that provided under THSteps.
  • Any services or supplies provided in connection with a routine physical examination except family planning services.
  • Any care or services payable under Title XVIII (Medicare).
  • Any service provided by an immediate relative of the recipient or member of the recipient's household.
  • Any services or supplies not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of the malformed body member.
  • Custodial care.
  • Any services provided to the recipient after a Utilization Review or medical review finding that such services are not medically necessary.
  • Any services or supplies that are payable through a third party.
  • Any service or supplies not specifically provided by the Texas Medical Assistance Program.

Disclaimer: This list is for convenient reference and does not have the effect of law, regulation, or policy. If there is a conflict between this list and law, regulations, and policy, the latter will prevail. If there is a question, use the appropriate provider manuals or filed releases for clarification.

 

C—1113 Qualified Hospital/Qualified Entity Policy and Procedures for Presumptive Eligibility Determinations

Revision 15-3; Effective July 1, 2015

 

TA 66, TA 74, TA 75, TA 76, TA 83, TA 86 and TP 42

Presumptive eligibility (PE) provides short-term medical coverage to pregnant women, Medicaid for Breast and Cervical Cancer (MBCC) applicants, children under age 19, parents and caretaker relatives of dependent children under age 19, and former foster care children. PE provides full fee-for-service Medicaid with the exception of pregnant women. Pregnant women receive ambulatory prenatal care only.

Qualified hospitals (QHs) determine PE for all groups except MBCC. 

Qualified entities (QEs) determine PE for pregnant women and MBCC applicants. For MBCC applicants, only QEs that are also Texas Department of State Health Services (DSHS) Breast and Cervical Cancer Services contractors can make MBCC PE determinations, following the process outlined in X-100, Application Processing.

 

C—1113.1 Eligible Groups

Revision 15-3; Effective July 1, 2015

 

The following groups can receive presumptive eligibility coverage:

  • Children:
    1. MA-Children Under 1 Presumptive — TA 74
    2. MA-Children 1–5 Presumptive — TA 75
    3. MA-Children 6–18 Presumptive — TA 76
  • Former Foster Care Children (MA-FFCC Presumptive — TA 83)
  • Pregnant Women (MA-Pregnant Women Presumptive — TP 42)
  • Parents and Other Caretaker Relatives (MA-Parents and Caretaker Relatives Presumptive — TA 86)

 

C—1113.2 Household Composition

Revision 15-3; Effective July 1, 2015

 

The QH/QE uses the non-taxpayer/non-tax dependent rules to determine the household composition.

 

C—1113.3 Modified Adjusted Gross Income (MAGI) Methodology

Revision 15-4; Effective October 1, 2015

 

The QH/QE uses a simplified MAGI methodology to determine if an individual meets the income requirements for PE. The income limits for each PE type of assistance are the same as the income limits for the associated regular Medicaid type of assistance. For example, MA-Children Under 1 Presumptive has the same income limit as MA-Children Under 1.

 

C—1113.4 Verifications

Revision 15-3; Effective July 1, 2015

 

The individual must attest to being:

  • a Texas resident, and
  • a United States citizen or an eligible immigrant.

For all other PE criteria, the individual's statement is acceptable verification. Additional forms of verification beyond an individual's statement are not required.

 

C—1113.5 Medical Effective Dates

Revision 15-4; Effective October 1, 2015

 

The medical effective date (MED) is the date the QH or QE determines the individual is presumptively eligible for Medicaid. If the individual is presumptively eligible, QH/QE staff give the individual Form H1266, Short-term Medicaid Notice: Approved. It informs the individual when the PE coverage begins and when the PE coverage ends, based on whether the individual applies for regular Medicaid.      

Note: An individual is not eligible for PE if they are currently receiving Medicaid, Children's Health Insurance Program (CHIP) or CHIP perinatal. 

If the individual does not apply for regular Medicaid, the PE coverage ends the last day of the month after the month of the PE determination (see scenario 1 below).

If the individual submits Form H1205, Texas Streamlined Application, or Form H1010, Texas Works Application for Assistance — Your Texas Benefits, HHSC staff determine whether the individual is eligible for regular Medicaid. If the individual is not eligible for regular Medicaid, the individual’s PE coverage ends the date that HHSC determines the individual is ineligible (see scenario 2 below). If the individual is eligible for regular Medicaid, the individual’s PE coverage ends when HHSC makes the Medicaid eligibility determination, following cutoff rules.

If an individual is Medicaid-eligible during the application month, the individual receives Medicaid from the first of that month through the PE MED. Regular Medicaid coverage for the ongoing period begins once the PE period ends (see scenarios 3 and 4 below). Exception: Since PE for pregnant women provides only limited prenatal services, ongoing Medicaid coverage overlays the PE coverage (see scenario 5 below).

Examples:

PE Scenarios
  1. Individual does not apply for regular Medicaid
A child is determined eligible for MA-Children 6–18 Presumptive on February 2. Her mother does not submit an application for regular Medicaid. The child’s PE coverage ends on March 31.
  1. Individual is ineligible for regular Medicaid
A child is determined eligible for MA-Children Under 1 Presumptive on April 4. Her father submits an application for regular Medicaid on the same date. HHSC determines on April 20 that the child is not eligible for regular Medicaid. Her PE coverage ends on April 20.
  1. Individual is eligible for regular Medicaid (HHSC makes eligibility determination before cutoff)
A child is determined eligible for MA-Children 1–5 Presumptive on March 6. His mother submits an application for regular Medicaid on the same date. HHSC determines on March 15 (before cutoff) that the child is eligible for regular Medicaid. His PE coverage ends March 31. He is certified for regular Medicaid effective March 1 to March 5 and April 1 through ongoing.
  1. Individual is eligible for regular Medicaid (HHSC makes eligibility determination after cutoff)
A former foster care child is determined eligible for MA-FFCC Presumptive on May 9. He submits an application for regular Medicaid on the same date. HHSC determines on May 22 (after cutoff) that the individual is eligible for regular Medicaid. His PE coverage ends June 30. He is certified for regular Medicaid effective May 1 to May 8 and July 1 through ongoing.
  1. Pregnant woman is eligible for regular Medicaid
A woman is determined eligible for MA-Pregnant Women Presumptive on June 4. She submits an application for regular Medicaid on the same date. HHSC determines on June 10 that the woman is eligible for regular Medicaid. Her PE coverage ends on June 30. Regular Medicaid overlays her PE coverage with an effective date of June 1.

 

C—1113.6 Periods of Presumptive Eligibility

Revision 15-3; Effective July 1, 2015

 

Pregnant women are allowed one PE period per pregnancy. 

For all other PE groups, an individual is allowed no more than one period of PE per two calendar years. Example: An individual receives MA-Children 6–18 Presumptive in June 2015. He cannot receive another period of PE until January 2017.

 

C—1113.7 Three Months Prior Coverage

Revision 15-3; Effective July 1, 2015

 

Three months prior coverage does not apply to presumptive eligibility. Eligibility for three months prior Medicaid coverage is determined when HHSC eligibility staff make a regular Medicaid determination, if requested.

 

C—1113.8 Application Processing

Revision 15-4; Effective October 1, 2015

 

QH/QE staff first must perform a PE portal inquiry to find out if an individual is currently receiving Medicaid, CHIP or CHIP perinatal or if the applicant has received a period of PE within the PE period limit.

QH/QE staff make the PE determination based on information the individual provides about citizenship/immigration status, Texas residency, income and household composition. To determine whether the individual is presumptively eligible, QH/QE staff fill out Form H1265, Presumptive Eligibility (PE) Worksheet, using the information the individual provides.

If the individual is presumptively eligible, QH/QE staff do the following:

  • Enter the individual’s demographic information and the PE type of assistance for which the individual is eligible into the PE portal. QH/QE staff use the PE portal to conduct limited inquiries and submit PE determinations.
  • Give the individual Form H1266, Short-term Medicaid Notice: Approved. QH/QE staff also help the individual complete and submit the regular Medicaid application via YourTexasBenefits.com if the individual wants to apply. Note: An individual is not required to submit a regular Medicaid application to receive PE Medicaid.

If the individual is not eligible for PE, QH/QE staff issue Form H1267, Short-term Medicaid Notice: Not Approved, to the individual and tell the individual about the right to apply for regular Medicaid.

 

C—1113.9 Due Dates and Processing Time Frames

Revision 15-3; Effective July 1, 2015

 

Within one business day of the PE determination, the QH/QE must submit the PE determination to HHSC through the PE portal.

 

C—1113.10 How to Become a Qualified Hospital or Qualified Entity

Revision 15-3; Effective July 1, 2015

 

Hospitals or entities that want to become qualified to make PE determinations must (1) submit to HHSC a notice of intent, (2) sign a Memorandum of Understanding, and (3) complete online training at the PE website at www.TexasPresumptiveEligibility.com.

 

C—1113.11 Presumptive Eligibility Forms

Revision 15-3; Effective July 1, 2015

 

Qualified hospital/qualified entity staff use the following forms in the presumptive eligibility process:

  • Form H1265, Presumptive Eligibility (PE) Worksheet — Completed by the QH/QE and used to determine if an applicant is presumptively eligible. 
  • Form H1266, Short-term Medicaid Notice: Approved — Completed by the QH/QE and given to an individual determined presumptively eligible. This form notifies the individual about PE coverage and lists the eligibility start date and end date, which is based on whether the individual submits an application for regular Medicaid. If an individual needs proof of Medicaid coverage before receiving their Medicaid identification card, the individual can present this form in an HHSC local eligibility determination office, and HHSC staff will provide the individual with Form H1027-A, Medicaid Eligibility Determination.
  • Form H1267, Short-term Medicaid Notice: Not Approved — Completed by the QH/QE and given to an individual determined ineligible for PE coverage. This form explains the reason for ineligibility and how to apply for regular Medicaid.

Related Policy
Processing Presumptive Eligibility Applications, A-124

 

C—1114 Guidelines for Providing Retroactive Coverage for Children and Medical Programs

Revision 18-2; Effective April 1, 2018

 

Medical Programs

When determining retroactive eligibility for children and pregnant women, use the applicable income, standard MAGI income disregard, and IRS monthly income thresholds charts.

 

March 2016 through February 2017

Federal Poverty Income Limits (FPIL)

Family Size

133% FPIL
(3-1-16)
TP 44, 34

144% FPIL
(3-1-16)
TP 48, 33

198% FPIL
(3-1-16)
TP 40, 43, 36, 35

1

$1,317

$1,426

$1,961

2

1,776

1,923

2,644

3

2,235

2,420

3,327

4

2,694

2,916

4,010

5

3,153

3,413

4,693

6

3,611

3,910

5,376

7

4,071

4,408

6,061

8

4,532

4,907

6,747

9

4,994

5,406

7,434

10

5,455

5,906

8,120

11

5,916

6,405

8,807

12

6,377

6,904

9,493

13

6,838

7,403

10,179

14

7,299

7,902

10,866

15

7,760

8,402

11,552

For each additional member

462

500

687

 

Family Size

200% FPIL
(3-1-16)
TP 02

201% FPIL
(3-1-16)
TA 84

202% FPIL
(3-1-16)
TA 85

400% FPIL
(3-1-16)
TA 77

413% FPIL
(3-1-16)
TP 70

1

$1,980

$1,990

$2,000

$3,960

$4,089

2

2,670

2,684

2,697

5,340

5,514

3

3,360

3,377

3,394

6,720

6,939

4

4,050

4,071

4,091

8,100

8,364

5

4,740

4,764

4,788

9,480

9,789

6

5,430

5,458

5,485

10,860

11,213

7

6,122

6,153

6,183

12,244

12,642

8

6,815

6,850

6,884

13,630

14,073

9

7,509

7,546

7,584

15,017

15,505

10

8,202

8,243

8,284

16,404

16,937

11

8,895

8,940

8,984

17,790

18,369

12

9,589

9,637

9,685

19,177

19,800

13

10,282

10,334

10,385

20,564

21,232

14

10,975

11,030

11,085

21,950

22,664

15

11,669

11,727

11,786

23,337

24,096

For each additional member

694

697

701

1,387

1,432

 

Five Percentage Points of FPIL

Family Size

2016 Monthly
Disregard Amount

1

$49.50

2

66.75

3

84.00

4

101.25

5

118.50

6

135.75

7

153.05

8

170.40

9

187.75

10

205.05

11

222.40

12

239.75

13

257.05

14

274.40

15

291.75

Per each additional person

17.35

 

IRS Monthly Income Thresholds

Type of Income

2016 Threshold

Apply Threshold Value in Form H1042,
Modified Adjusted Gross Income (MAGI)
Worksheet: Medicaid and CHIP

Unearned Income

$87.50

  • Pages 5-7, Step 3, Line 6
  • Pages 5-7, Step 3, Line 8

Earned Income

525.00

  • Pages 5-7, Step 3, Line 7

 

March 2017 through February 2018

Federal Poverty Income Limits (FPIL)

Family Size

133% FPIL
(3-1-17)
TP 44, 34, TA 76

144% FPIL
(3-1-17)
TP 48, 33, TA 75

198% FPIL
(3-1-17)
TP 40, 42, 43, 36, 35, TA 74

1

$1,337

$1,448

$1,990

2

1,800

1,949

2,680

3

2,264

2,451

3,370

4

2,727

2,952

4,059

5

3,190

3,454

4,749

6

3,654

3,956

5,439

7

4,117

4,457

6,129

8

4,580

4,959

6,818

9

5,043

5,460

7,508

10

5,507

5,962

8,198

11

5,970

6,464

8,887

12

6,433

6,965

9,577

13

6,897

7,467

10,267

14

7,360

7,968

10,956

15

7,823

8,470

11,646

For each additional member

464 502 690

 

Family Size

200% FPIL
(3-1-17)
TA 41

201% FPIL
(3-1-17)
TA 84

202% FPIL
(3-1-17)
TA 85

400% FPIL
(3-1-17)
TA 77

413% FPIL
(3-1-17)
TP 70

1

$2,010

$2,021

$2,031

$4,020

$4,151

2

2,707

2,721

2,734

5,414

5,590

3

3,404

3,421

3,438

6,807

7,028

4

4,100

4,121

4,141

8,200

8,467

5

4,797

4,821

4,845

9,594

9,906

6

5,494

5,521

5,549

10,987

11,344

7

6,190

6,221

6,252

12,380

12,783

8

6,887

6,922

6,956

13,774

14,221

9

7,584

7,622

7,660

15,167

15,660

10

8,280

8,322

8,363

16,560

17,099

11

8,977

9,022

9,067

17,954

18,537

12

9,674

9,722

9,771

19,347

19,976

13

10,370

10,422

10,474

20,740

21,415

14

11,067

11,122

11,178

22,134

22,853

15

11,764

11,823

11,881

23,527

24,292

For each additional member

697

701

704

1,394

1,439

 

Five Percentage Points of FPIL

Family Size

2017 Monthly
Disregard Amount

1

$50.25

2

67.70

3

85.10

4

102.50

5

119.95

6

137.35

7

154.75

8

172.20

9

189.60

10

207.00

11

224.45

12

241.85

13

259.25

14

276.70

15

294.10

Per each additional person

17.45

 

IRS Monthly Income Thresholds

Type of
Income
2017
Threshold
Apply Threshold Value in Form H1042,
Modified Adjusted Gross Income (MAGI)
Worksheet: Medicaid and CHIP

Unearned Income

$87.50

  • Pages 5-7, Step 3, Line 6
  • Pages 5-7, Step 3, Line 8

Earned Income

$525.00

  • Pages 5-7, Step 3, Line 7

 

C— Immunization Terms

Revision 13-3; Effective July 1, 2013

 

TANF and Medical Programs

Immunization by inoculation or vaccination protects against childhood diseases. Except for tetanus, these diseases are contagious. Encourage individuals to follow the Texas Department of Health's recommended schedule found on Form H1012, Immunization Record. If a child is on an alternate schedule refer to A-2125, Immunizations.

The following are descriptions of the diseases and symptoms associated with immunizations.

  • Diphtheria — An acute, bacterial illness that causes a sore throat and a fever and sometimes causes more serious or even fatal complications.
  • Haemophilus Influenza Type b (HIB) — A bacterium that can cause meningitis and pneumonia and infect other body systems such as blood, joints, bones and soft tissue under the skin, throat, and the covering of the heart.
  • Hepatitis A — An infection of the liver caused by the Hepatitis A virus.
  • Hepatitis B — An infection of the liver caused by the Hepatitis B virus.
  • Measles — An acute, highly contagious viral disease involving the respiratory tract that causes a characteristic rash, fever, runny nose, sore eyes, and cough.
  • Mumps — An acute viral disease mainly of childhood. It is characterized by a swelling of the parotid (salivary) glands on one or both sides and may cause fever, headache, and difficulty swallowing may develop.
  • Pertussis (Whooping Cough) — An acute highly contagious respiratory disease characterized by a severe attack of coughing that ends in a characteristic "whoop" as breath is drawn in.
  • Poliomyelitis (Polio – once known as "infantile paralysis") — An infectious disease that may lead to extensive paralysis of the muscles.
  • Rubella (German Measles) — A viral infection characterized by a mild fever, swollen glands in the neck and a rash that lasts up to three days.
  • Tetanus (Lockjaw) — A very serious disease of the central nervous system caused by an infection of a wound that makes an individual unable to open his/her mouth or swallow and causes muscle spasms in the jaw, neck, leg or other muscles.
  • Varicella (Chickenpox) — A highly contagious viral infection which presents as a generalized, itchy, vesicular rash. The rash begins as smooth, red spots which develop into blisters that last three to four days before forming crusty scabs.

 

C—1116 Managed Care Plans

Revision 18-1; Effective January 1, 2018

 

Medical Programs

STAR – Bexar Service Area

(Counties: Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina, Wilson)

Plan Code Plan Name Member Services
40 Superior HealthPlan 800-783-5386
42 Community First Health Plans 800-434-2347
43 AETNA Better Health 800-248-7767
44 Amerigroup 800-600-4441

 

STAR – Dallas Service Area

(Counties: Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, Rockwall)

Plan Code Plan Name Member Services
90 Amerigroup 800-600-4441
93 Parkland HEALTH First 888-672-2277
95 Molina Healthcare of Texas 866-449-6849

 

STAR – El Paso Service Area

(Counties: El Paso and Hudspeth)

Plan Code Plan Name Member Services
36 Superior HealthPlan 800-783-5386
37 El Paso First Premier Plan 877-532-3778
31 Molina Healthcare of Texas 866-449-6849

 

STAR – Harris Service Area

(Counties: Austin, Brazoria, Fort Bend, Galveston, Harris, Matagorda, Montgomery, Waller, Wharton)

Plan Code Plan Name Member Services
71 Amerigroup 800-600-4441
72 Texas Children's Health Plan 866-959-2555
79 Community Health Choice 888-760-2600
7G Molina Healthcare of Texas 866-449-6849
7H UnitedHealthcare Community Plan 888-887-9003

 

STAR – Hidalgo Service Area

(Counties: Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy, Zapata)

Plan Code Plan Name Member Services
H4 Driscoll Children's Health Plan 855-425-3247
H3 Molina Healthcare of Texas 866-449-6849
H2 Superior HealthPlan 800-783-5386
H1 UnitedHealthcare Community Plan 888-887-9003

 

STAR – Jefferson Service Area

(Counties: Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler, Walker)

Plan Code Plan Name Member Services
8G Amerigroup 800-600-4441
8H Community Health Choice 888-760-2600
8J Molina Healthcare of Texas 866-449-6849
8K Texas Children’s Health Plan 866-959-2555
8L UnitedHealthcare Community Plan 888-887-9003

 

STAR – Lubbock Service Area

(Counties: Carson, Crosby, Deaf Smith, Floyd, Garza, Hale, Hockley, Hutchinson, Lamb, Lubbock, Lynn, Potter, Randall, Swisher, Terry)

Plan Code Plan Name Member Services
50 FirstCare STAR 800-431-7798
52 Superior HealthPlan 800-783-5386
53 Amerigroup 800-600-4441

 

STAR – Nueces Service Area

(Counties: Aransas, Bee, Brooks, Calhoun, Goliad, Jim Wells, Karnes, Kenedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio, Victoria)

Plan Code Plan Name Member Services
82 Driscoll Children's Health Plan 877-220-6376
83 Superior HealthPlan 800-783-5386
88 CHRISTUS Health Plan 877-428-3057

 

STAR – Tarrant Service Area

(Counties: Denton, Hood, Johnson, Parker, Tarrant, Wise)

Plan Code Plan Name Member Services
63 Amerigroup 800-600-4441
66 Cook Children's Health Plan 800-964-2247
67 AETNA Better Health 800-306-8612

 

STAR – Travis Service Area

(Counties: Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis, Williamson)

Plan Code Plan Name Member Services
1P Blue Cross Blue Shield of Texas 888-292-4480
1N Sendero Health Plans 855-526-7388
1A Dell Children's Health Plan 888-596-0268
10 Superior HealthPlan 800-783-5386

 

STAR – Medicaid RSA West Texas Service Area

 

(Counties: Andrews, Archer, Armstrong, Bailey, Baylor, Borden, Brewster, Briscoe, Brown, Callahan, Castro, Childress, Clay, Cochran, Coke, Coleman, Collingsworth, Concho, Cottle, Crane, Crockett, Culberson, Dallas, Dawson, Dickens, Dimmit, Donley, Eastland, Ector, Edwards, Fisher, Foard, Frio, Gaines, Glasscock, Gray, Hall, Hansford, Hardeman, Hartley, Haskell, Hemphill, Howard, Irion, Jack, Jeff Davis, Jones, Kent, Kerr, Kimble, King, Kinney, Knox, LaSalle, Lipscomb, Loving, Martin, Mason, McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Palo Pinto, Parmer, Pecos, Presidio, Reagan, Real, Reeves, Roberts, Runnels, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sutton, Taylor, Terrell, Throckmorton, Tom Green, Upton, Uvalde, Val Verde, Ward, Wheeler, Wichita, Wilbarger, Winkler, Young, Zavala)

Plan Code Plan Name Member Services
W2 Amerigroup 800-600-4441
W3 Superior HealthPlan 877-644-4494
W4 FirstCare STAR 800-431-7798

 

STAR – Medicaid RSA Northeast Texas Service Area

(Counties: Anderson, Angelina, Bowie, Camp, Cass, Cherokee, Cooke, Delta, Fannin, Franklin, Grayson, Gregg, Harrison, Henderson, Hopkins, Houston, Lamar, Marion, Montague, Morris, Nacogdoches, Panola, Rains, Red River, Rusk, Sabine, San Augustine, Shelby, Smith, Titus, Trinity, Upshur, Van Zandt, Wood)

Plan Code Plan Name Member Services
N1 Amerigroup 800-600-4441
N2 Superior HealthPlan 800-783-5386

 

STAR – Medicaid RSA Central Texas Service Area

(Counties: Bell, Blanco, Bosque, Brazos, Burleson, Colorado, Comanche, Coryell, DeWitt, Erath, Falls, Freestone, Gillespie, Gonzales, Grimes, Hamilton, Hill, Jackson, Lampasas, Lavaca, Leon, Limestone, Llano, Madison, McLennan, Milam, Mills, Robertson, San Saba, Somervell, Washington)

Plan Code Plan Name Member Services
C1 Amerigroup 800-600-4441
C2 Superior HealthPlan 877-644-4494
C3 RightCare from Scott and White Health Plan 855-897-4448

 

STAR+PLUS – Bexar Service Area

(Counties: Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina, Wilson)

Plan Code Plan Name Member Services
45 Amerigroup 800-600-4441
46 Molina Healthcare of Texas 866-449-6849
47 Superior HealthPlan 800-516-4501

 

STAR+PLUS – Dallas Service Area

(Counties: Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, Rockwall)

Plan Code Plan Name Member Services
9F Molina Healthcare of Texas 866-449-6849
9H Superior HealthPlan 800-516-4501

 

STAR+PLUS – El Paso Service Area

(Counties: El Paso and Hudspeth)

Plan Code Plan Name Member Services
34 Amerigroup 800-600-4441
33 Molina Healthcare of Texas 866-449-6849

 

STAR+PLUS – Harris Service Area

(Counties: Austin, Brazoria, Fort Bend, Galveston, Harris, Matagorda, Montgomery, Waller, Wharton)

Plan Code Plan Name Member Services
7P Amerigroup 800-600-4441
7S Molina Healthcare of Texas 866-449-6849
7R UnitedHealthcare Community Plan 888-887-9003

 

STAR+PLUS – Hidalgo Service Area

(Counties: Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy, Zapata)

Plan Code Plan Name Member Services
H7 Cigna HealthSpring 877-653-0327
H6 Molina Healthcare of Texas 866-449-6849
H5 Superior HealthPlan 866-516-4501

 

STAR+PLUS – Jefferson Service Area

(Counties: Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler, Walker)

Plan Code Plan Name Member Services
8R Amerigroup 800-600-4441
8T Molina Healthcare of Texas 866-449-6849
8S UnitedHealthcare Community Plan 888-887-9003

 

STAR+PLUS – Lubbock Service Area

(Counties: Carson, Crosby, Deaf Smith, Floyd, Garza, Hale, Hockley, Hutchinson, Lamb, Lubbock, Lynn, Potter, Randall, Swisher, Terry)

Plan Code Plan Name Member Services
5A Amerigroup 800-600-4441
5B Superior HealthPlan 866-516-4501

 

STAR+PLUS – Nueces Service Area

(Counties: Aransas, Bee, Brooks, Calhoun, Goliad, Jim Wells, Karnes, Kenedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio, Victoria)

Plan Code Plan Name Member Services
85 UnitedHealthcare Community Plan 888-887-9003
86 Superior HealthPlan 800- 516-4501

 

STAR+PLUS – Tarrant Service Area

(Counties: Denton, Hood, Johnson, Parker, Tarrant, Wise)

Plan Code Plan Name Member Services
69 Amerigroup 800-600-4441
6C Cigna HealthSpring 877-966-9272

 

STAR+PLUS – Travis Service Area

(Counties: Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis, Williamson)

Plan Code Plan Name Member Services
19 Amerigroup 800-600-4441
18 UnitedHealthcare Community Plan 888-887-9003

 

STAR+PLUS– Medicaid RSA West Texas Service Area

(Counties: Andrews, Archer, Armstrong, Bailey, Baylor, Borden, Brewster, Briscoe, Brown, Callahan, Castro, Childress, Clay, Cochran, Coke, Coleman, Collingsworth, Concho, Cottle, Crane, Crockett, Culberson, Dallas, Dawson, Dickens, Dimmit, Donley, Eastland, Ector, Edwards, Fisher, Foard, Frio, Gaines, Glasscock, Gray, Hall, Hansford, Hardeman, Hartley, Haskell, Hemphill, Howard, Irion, Jack, Jeff Davis, Jones, Kent, Kerr, Kimble, King, Kinney, Knox, LaSalle, Lipscomb, Loving, Martin, Mason, McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Palo Pinto, Parmer, Pecos, Presidio, Reagan, Real, Reeves, Roberts, Runnels, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sutton, Taylor, Terrell, Throckmorton, Tom Green, Upton, Uvalde, Val Verde, Ward, Wheeler, Wichita, Wilbarger, Winkler, Young, Zavala)

Plan Code Plan Name Member Services
W5 Amerigroup 800-600-4441
W6 Superior HealthPlan 877-644-4494

 

STAR+PLUS – Medicaid RSA Northeast Texas Service Area

(Counties: Anderson, Angelina, Bowie, Camp, Cass, Cherokee, Cooke, Delta, Fannin, Franklin, Grayson, Gregg, Harrison, Henderson, Hopkins, Houston, Lamar, Marion, Montague, Morris, Nacogdoches, Panola, Rains, Red River, Rusk, Sabine, San Augustine, Shelby, Smith, Titus, Trinity, Upshur, Van Zandt, Wood)

Plan Code

Plan Name

Member Services

N3

Cigna-HealthSpring

877-653-0327

N4

UnitedHealth Care

888-887-9003

 

STAR+PLUS – Medicaid RSA Central Texas Service Area

(Counties: Bell, Blanco, Bosque, Brazos, Burleson, Colorado, Comanche, Coryell, DeWitt, Erath, Falls, Freestone, Gillespie, Gonzales, Grimes, Hamilton, Hill, Jackson, Lampasas, Lavaca, Leon, Limestone, Llano, Madison, McLennan, Milam, Mills, Robertson, San Saba, Somervell, Washington)

Plan Code

Plan Name

Member Services

C4

Superior HealthPlan

866-516-4501

C5

UnitedHealth Care

888-887-9003

 

STAR Health – Statewide

Plan Code

Plan Name

Member Services

1E

Superior HealthPlan

866-912-6283

 

STAR Kids - Bexar Service Area

(Counties: Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina, Wilson)

Plan Code

Plan Name

Member Services

KA

Community First Health Plans

855-607-7827

KE

Superior HealthPlan

844-590-4883

 

STAR Kids - Dallas Service Area

(Counties: Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, Rockwall)

Plan Code

Plan Name

Member Services

K2

Amerigroup

844-756-4600

K9

Children’s Medical Center

800-947-4969

 

STAR Kids - El Paso Service Area

(Counties: El Paso and Hudspeth)

Plan Code

Plan Name

Member Services

K3

Amerigroup

844-756-4600

KF

Superior HealthPlan

844-590-4883

 

STAR Kids - Harris Service Area

(Counties: Austin, Brazoria, Fort Bend, Galveston, Harris, Matagorda, Montgomery, Waller, Wharton)

Plan Code

Plan Name

Member Services

K4

Amerigroup

844-756-4600

KM

Texas Children’s Health Plan

800-659-5764

KQ

UnitedHealthcare Community Plan

877-597-7799

 

STAR Kids - Hidalgo Service Area

(Counties: Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy, Zapata)

Plan Code

Plan Name

Member Services

KC

Driscoll Children’s Health Plan

877-324-7543

KG

Superior HealthPlan

844-590-4883

KR

UnitedHealthcare Community Plan

877-597-7799

 

STAR Kids - Jefferson Service Area

(Counties: Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler, Walker)

Plan Code

Plan Name

Member Services

KN

Texas Children’s Health Plan

800-659-5764

KS

UnitedHealthcare Community Plan

877-597-7799

 

STAR Kids - Lubbock Service Area

(Counties: Carson, Crosby, Deaf Smith, Floyd, Garza, Hale, Hockley, Hutchinson, Lamb, Lubbock, Lynn, Potter, Randall, Swisher, Terry)

Plan Code

Plan Name

Member Services

K5

Amerigroup

844-756-4600

KH

Superior HealthPlan

844-590-4883

 

STAR Kids - Nueces Service Area

(Counties: Aransas, Bee, Brooks, Calhoun, Goliad, Jim Wells, Karnes, Kenedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio, Victoria)

Plan Code

Plan Name

Member Services

KD

Driscoll Children’s Health Plan

877-324-7543

KV

Superior HealthPlan

844-590-4883

 

STAR Kids - Tarrant Service Area

(Counties: Denton, Hood, Johnson, Parker, Tarrant, Wise)

Plan Code

Plan Name

Member Services

K1

Aetna

844-787-5437

KB

Cook Children’s Health Plan

844-843-0004

 

STAR Kids - Travis Service Area

(Counties: Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis, Williamson)

Plan Code

Plan Name

Member Services

K8

Blue Cross Blue Shield of Texas

877-688-1811

KL

Superior HealthPlan

844-590-4883

 

STAR Kids - Medicaid RSA - West Texas Service Area

(Counties: Andrews, Archer, Armstrong, Bailey, Baylor, Borden, Brewster, Briscoe, Brown, Callahan, Castro, Childress, Clay, Cochran, Coke, Coleman, Collingsworth, Concho, Cottle, Crane, Crockett, Culberson, Dallas, Dawson, Dickens, Dimmit, Donley, Eastland, Ector, Edwards, Fisher, Foard, Frio, Gaines, Glasscock, Gray, Hall, Hansford, Hardeman, Hartley, Haskell, Hemphill, Howard, Irion, Jack, Jeff Davis, Jones, Kent, Kerr, Kimble, King, Kinney, Knox, LaSalle, Lipscomb, Loving, Martin, Mason, McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Palo Pinto, Parmer, Pecos, Presidio, Reagan, Real, Reeves, Roberts, Runnels, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sutton, Taylor, Terrell, Throckmorton, Tom Green, Upton, Uvalde, Val Verde, Ward, Wheeler, Wichita, Wilbarger, Winkler, Young, Zavala)

Plan Code

Plan Name

Member Services

K6

Amerigroup

844-756-4600

KJ

Superior HealthPlan

844-590-4883

 

STAR Kids - Medicaid RSA - Northeast Texas Service Area

(Counties: Anderson, Angelina, Bowie, Camp, Cass, Cherokee, Cooke, Delta, Fannin, Franklin, Grayson, Gregg, Harrison, Henderson, Hopkins, Houston, Lamar, Marion, Montague, Morris, Nacogdoches, Panola, Rains, Red River, Rusk, Sabine, San Augustine, Shelby, Smith, Titus, Trinity, Upshur, Van Zandt, Wood)

Plan Code

Plan Name

Member Services

KP

Texas Children’s Health Plan

800-659-5764

KU

UnitedHealthcare Community Plan

877-597-7799

 

STAR Kids - Medicaid RSA - Central Texas Service Area

(Counties: Bell, Blanco, Bosque, Brazos, Burleson, Colorado, Comanche, Coryell, DeWitt, Erath, Falls, Freestone, Gillespie, Gonzales, Grimes, Hamilton, Hill, Jackson, Lampasas, Lavaca, Leon, Limestone, Llano, Madison, McLennan, Milam, Mills, Robertson, San Saba, Somervell, Washington)

Plan Code

Plan Name

Member Services

K7

Blue Cross Blue Shield of Texas

877-688-1811

KT

UnitedHealthcare Community Plan

877-597-7799

 

Dental – Statewide

Plan Code Plan Name Member Services
1M DentaQuest 800-516-0165
1J MCNA Dental 855-691-6262

 

Note: Each region has a designated representative whom managed care plan staff contact to resolve issues related to eligibility, county code assignments and other concerns for individuals enrolled in managed care. The plan representative has access to the same information in an individual’s record as the individual’s medical provider does.

Related Policy
Managed Care, A-821.2
Releasable Information for Medicaid Providers and Their Contractors, B-1230
Office of the Ombudsman, B-1420

 

C—1117 Texas Health Steps (THSteps) Quick Reference Guide and Recipient Enrollment Script

Revision 16-4; Effective October 1, 2016

 

Children's Medicaid

Medicaid Managed Care (MMC)/THSteps QUICK REFERENCE GUIDE STAR+PLUS (Dual Eligibles)

The caller's identity must be verified.

Eight Steps to VERIFICATION and ENROLLMENT

  • Medicaid Identification (ID) No. or Social Security Number (SSN)
  • Name
  • Address
  • Primary Language Spoken in Home
  • Phone No.
  • DOB
  • Third-Party Resources (Private Insurance)
  • Pregnancy

POINTS OF EDUCATION

  • Introduction (Name, program)
  • Medicaid Managed Care Enrollment-Medicaid Managed Care Recipients
  1. Explain Managed Care
  2. Explain that STAR+PLUS for dual eligibles is for LONG TERM CARE Services only
  3. Explain recipients will continue to use your doctors and hospitals as before.
  4. Explain your doctor's office will continue to bill Medicare and Medicaid for your visit, you do not need to show your STAR+PLUS Health Plan ID card.
  5. Explain that dual eligibles will still receive their prescription drugs through Medicare.
  6. Explain the enrollment will be effective in 15-45 days and traditional Medicaid is in effect until then
  7. Enroll recipient. Give health plan's member services phone number.
  8. Explain they will receive an ID card from the health plan with the phone number on it.
  9. STAR+PLUS plan changes, call the STAR+PLUS HelpLine

For more information on drug coverage for dual eligibles:

If you are on Medicare and Medicaid, you will continue to use Medicare for your regular health care needs and all prescription drugs. You will use STAR+PLUS only for your Medicaid long-term service and support needs. Enrollment in STAR+PLUS will not change the way you use Medicare.

Resource Directory
Resource List Toll Free Numbers TDD LINE
2-1-1-Information and Referral 2-1-1, Option 1 2-1-1, Option 1
Medicaid Hotline Number 1-800-252-8263 1-800-735-2988
HHS Ombudsman Managed Care Assistance Team 1-866-566-8989 7-1-1
HHSC 1-888-834-7406 1-888-425-6889
Social Security Administration (SSI) 1-800-772-1213 1-800-325-0778
Billing Questions Hotline 1 800-335-8957 1-800-735-2988

 

Recipient Enrollment Script for STAR+PLUS Dual Eligibles
Expanded (11/06)

Introduction

Standard Greeting to include your name, program and purpose for calling. For example: Hello, may I speak with [case name]: Hello, Mr/Mrs_______________________. My name is _________________.

The caller's identity must be verified.

Eight Steps to VERIFICATION and ENROLLMENT

  • Medicaid Identification (ID) No. or Social Security Number (SSN)-Do you have Your Texas Benefits Medicaid ID card handy? Will you read the number that appears on your card below your name?
  • Name-Is this your name?
  • Address-Are you still living at this address?
  • Primary Language Spoken in Home-Document what language
  • Phone No. -Is this the correct phone number?
  • DOB-Is this your DOB?
  • Third Party Resources (Private Insurance)-Does your child have any private health insurance?
  • Pregnancy-Are you or anyone in your home pregnant at this time?
  • Special Health Care Questions-3 questions for each adult:

Health Plan Information-STAR+PLUS for Dual Eligibles in Harris, Harris Expansion, Travis, Nueces and Bexar Service Areas

  1. Explain Managed Care STAR + PLUS "Let me tell you a little about the STAR+PLUS program. STAR+PLUS is a managed care program that provides Medicaid long-term services and supports in your area. Long-term services and supports may include personal attendant services, adaptive aids, adult foster home service, assisted living, nursing services, and medical supplies. There are different STAR+PLUS health plans in your area that will provide these services. You must choose a STAR+PLUS health plan for your long-term services and supports, or a plan will be chosen for you. You will not choose a primary care provider.
  2. Explain that STAR+PLUS for dual eligibles is for long-term services and supports ONLY. For STAR+PLUS members who are also on Medicare, STAR+PLUS only provides long-term services and supports. You will use Medicare for your regular health care needs and prescription drugs, just as you did before.
  3. Explain recipients will continue to use your doctors and hospitals as before. You will continue to go to your regular Medicare doctor for general health care needs. STAR+PLUS also does not affect the way you receive hospital services.
  4. Explain your doctor's office will continue to bill Medicare and Medicaid for your visit; you do not need to show your STAR+PLUS Health Plan ID card. Because STAR+PLUS only includes long-term services and supports, make sure you bring your Medicare card with you to all of your doctor visits. You do not need to bring your STAR+PLUS health plan ID card.
  5. Explain that dual eligibles will still receive prescription drugs through Medicare. You will continue to use your Medicare Part D plan for all of your prescription drugs. STAR+PLUS does not include prescriptions.
  6. Enroll recipient. Give health plan's member services phone number. Have you received a STAR+PLUS enrollment packet? The packet has an enrollment form for you to choose a health plan, as well as other program information and the health plan provider directories. Have you already enrolled? If not, I will be glad to help you enroll today!
  7. Explain the enrollment will be effective in 15-45 days and traditional Medicaid is in effect until then. Advise the client a new Your Texas Benefits Medicaid ID card will not be issued due to a change to a Medicaid Managed Care health plan.

  8. Explain they will receive an ID card from the health plan with the phone number on it. You will also receive an ID card from the health plan you chose. The health plan ID card will have a phone number for you to call with any questions.

  9. STAR+PLUS plan changes, call the STAR+PLUS HelpLine. In the STAR+PLUS program you may change health plans at any time. Just call the STAR+PLUS HelpLine. The phone number is 1-800-964-2777.

  10. Summary

  • Any Questions regarding your benefits?

  • Provide your name

Resource Directory
Resource List Toll Free Numbers TDD LINE
2-1-1-Information and Referral 2-1-1, Option 1 2-1-1, Option 1
STAR Help Line 1-800-964-2777 1-800-267-5008
Medicaid Hotline Number 1-800-252-8263 1-800-735-2988
HHS Ombudsman Managed Care Assistance Team 1-866-566-8989 7-1-1
HHSC 1-888-834-7406 1-888-425-6889
Social Security Administration (SSI) 1-800-772-1213 1-800-325-0778
Billing Questions Hotline 1 800-335-8957 1-800-735-2988



 

C—1118 Health Care Orientation Quick Reference Guide and Enrollment Script

Revision 16-4; Effective October 1, 2016

TP 43, TP 44 and TP 48

MMC/THSteps QUICK SCRIPT REFERENCE GUIDE STAR/PCCM Expansion/FFS/STAR+PLUS (except for Dual Eligibles)

Effective 11/1/06

STEPS TO VERIFICATION and ENROLLMENT

Verification

  • Medicaid ID No. or SSN
  • Name
  • Address
  • Phone No.
  • DOB

Enrollment

  • Third Party Resources (Private Insurance)
  • Pregnancy
  • Primary Language Spoken in Home
  • Special Health Care Questions-STAR Only

If all family members are over 21, only provide information from the first five bullets below and MTP as appropriate.

15 Steps to EDUCATION

  • Introduction (Name, program, Health Care Orientation) (Face to face HCO's should receive "Helpful Toll-free Number" Handout)
  • Medicaid Managed Care Enrollment-Medicaid Managed Care Recipients
  1. Explain Managed Care and PCP.
  2. Explain about PCP / emergency rooms.
  3. Explain about specialist and referrals.
  4. Explain about preventive health checkups.
  5. Explain the STAR/STAR+PLUS enrollment will be effective in 15-45 days and traditional Medicaid is in effect until then. PCCM Expansion area recipients are automatically enrolled.
  6. Enroll recipient. Give health plan's member services phone number.
  7. Explain they will receive an ID card from the health plan (except PCCM).
  8. Other education is provided as necessary (i.e., TP40 education script, newborn education).
  9. Managed Care changes – Plan and/or PCP how often, who to call to make changes.
  10. NorthSTAR script-Dallas SA only.
  • Medicaid Program Knowledge – don't pay bills, what Medicaid covers, excluding SSI recipients
  • Your Texas Benefits Medicaid ID card - STAR plan, PCCM PCP, restrictions.
  • Maintaining Eligibility – reading mail, sending back information, receiving checkups
  • THSteps Program Knowledge - under age 21 – preventive checkups, medical and dental
  • Checkup Schedule & Components – when a checkup is due and what happens at a checkup
  • Medical and Dental Providers – Give choices/handout or we can have a list mailed, immediate call 1-877-847-8377.
  • How to Schedule an Appointment – offer to help or give the toll free number; keeping/canceling appointments.
  • Case Management for Children/Pregnant Women – health risk or health condition, trouble finding services, CMI Script
  • Medical Transportation – available benefit, call for transportation assistance
  • CHIP – any uninsured children in the household?
  • WIC –Pregnant Women or child in the family who is under 5
  • Summary – HCO provided, Enrollment information, Medical and dental providers and their telephone numbers, verify address and phone, assistance scheduling appointment.
Resource Directory
Resource List Toll Free Numbers TDD LINE
2-1-1-Information and Referral 2-1-1, Option 1 2-1-1, Option 1
Billing Questions Hotline (Fee-for-Service) 1 800-335-8957 1-800-735-2988
HHSC 1-888-834-7406 1-888-425-6889
Medicaid Hotline Number 1-800-252-8263 1-800-735-2988
Medical Transportation Program 1-877-633-8747 1-800-735-2988
PCCM 1-888-302-6688 1-800-735-2988
Social Security Administration (SSI) 1-800-772-1213 1-800-325-0778
STAR/STAR+PLUS/NS Help Line 1-800-964-2777 1-800-267-5008
HHS Ombudsman Managed Care Assistance Team 1-866-566-8989 7-1-1
Texas Health Steps (& Case Mgmt) 1-877-847-8377 1-800-735-2988
Children's Health Insurance Program (CHIP) 1-800-647-6558 1-800-735-2988
WIC 1-800-942-3678 1-800-735-2988

Health Care Orientation/Enrollment Script STAR/PCCM Expansion/FFS/STAR+PLUS (except for Dual Eligibles)

Expanded (Effective 11/1/06)

Introduction

Standard Greeting to include your name, program and purpose for calling. For example: Hello, may I speak with [case name]: Hello, Mr./Mrs._______________________. My name is _________________. Since your child/children are new to Medicaid, a state law requires that you received what is known as a Health Care Orientation. This will only take a few minutes and I will give you some valuable information about how to use your child's/children's Medicaid benefits.

Did I verify the caller's identity?

8 Steps to VERIFICATION and ENROLLMENT

  • Medicaid ID No. or SSN-Do you have Your Texas Benefits Medicaid ID card handy? Will you read the number that appears on the card below your child's name?
  • Name-Is this the name of your child?
  • Address-Are you still living at this address?
  • Primary Language Spoken in Home-Ask and Document what language
  • Phone No. -Is this the correct phone number?
  • DOB-Is this your child's date of birth?
  • Third Party Resources (Private Insurance)-Does your child have any private health insurance?
  • Pregnancy-Are you or anyone in your home pregnant at this time?
  • Special Questions: Ask at initial enrollment only.

15 Steps to EDUCATION

Health Plan Information-Only for Managed Care Areas

  1. Explain Managed Care and Primary Care Provider. STAR/STAR+PLUS: "Let me tell you a little about the STAR/STAR+PLUS program. The STAR/STAR+PLUS program is the Medicaid Managed Care program plans in your area." Managed care means that you will receive your Medicaid services through a health plan. You only have 30 days from the date you are certified to select a health plan and a primary care provider. The primary care provider can be a doctor, specially trained nurse, clinic or health center. If you don't choose, the STAR/STAR + PLUS program will pick a health plan and primary care provider for you. The primary care provider is available 24 hours a day, 7 days a week to coordinate care for you and/or your child/children. Have you received an enrollment packet? This is a large white envelope with the different health plan booklets, enrollment form and instructions. Have you already enrolled? If not, I will be glad to help you enroll today! (or change plan if they have been defaulted) PCCM Expansion: "Let me tell you a little about the PCCM program. The PCCM program is the Medicaid managed care program in your area." The PCCM program will send you a welcome letter and a member handbook for your child/children. The Primary Care Provider (PCP) can be a doctor, specially trained nurse, clinic or health center. The PCP is available 24/7 to coordinate care for your child/children.
  2. Explain about primary care providers and emergency rooms. Your child's primary care provider is the one you contact first when your child/children needs/need any kind of medical health care. Unless it is an emergency, you should contact your primary care provider before you take your child to the emergency room. An emergency would be a problem or condition, including severe pain that is so serious that waiting for routine care might result in serious harm. In an emergency, you may not have time to contact the primary care provider, in that case, call 911 or take your child to the nearest emergency room.
  3. Explain referrals: Referrals to specialists for both STAR/STAR+PLUS and PCCM Expansion recipients must be obtained through the primary care provider. However, families do not need a referral for the following services: Family Planning, Eye Care, Behavioral Health and THSteps medical/dental checkups. The primary care provider will refer your child/children to specialists or hospitals when needed.
  4. Preventive checkups: THSteps: Recipients under 21 are eligible for preventive medical and dental checks-ups through THSteps program no matter what service delivery system is in their area. STAR/STAR+PLUS: Adults receive one annual preventive exam per year. PCCM Expansion: Adults will receive services currently eligible in traditional Medicaid.
  5. Tell the family the effective date of the enrollment: Advise the client a new Your Texas Benefits Medicaid ID card will not be issued due to a change to a managed care health plan. PCCM Expansion recipients are automatically enrolled.
  6. Enroll family if they are in a STAR/STAR+PLUS area. Once the family has enrolled, provide them with the name and phone number of their health plan and the primary care provider. If the family is in the PCCM Expansion area, PCCM will send you a welcome letter and a member handbook for your child/children. You will need to contact the PCCM helpline if you want to change their primary care provider. (For pregnant women, go to #8)
  7. Explain the recipients will receive a Your Texas Benefits Medicaid ID card. STAR/STAR+PLUS: After the recipient is enrolled in the STAR/STAR+PLUS program, a regular Your Texas Benefits Medicaid ID card will be mailed. The recipient will also receive a member ID card from the plan (except in the PCCM expansion area).
  8. Pregnant Women: If applicable, expand education to include TP40 (pregnant women) I information.

STAR/STAR+PLUS: Pregnant woman - ask "Are you currently seeing a provider for your prenatal care?" Inform - Pregnant women must choose a plan and primary care provider within 15 days from their Medicaid application. The enrollment will take effect as soon as the recipient is found eligible for Medicaid. All efforts will be made to expedite the enrollment. If that is not possible, the enrollment will be effective within 15-45 days. Remind the recipient the importance of selecting a plan for herself and the baby since the recipient will not be able to change the baby's plan until the baby is three months old. After the baby is born, the recipient should call the plan to pick a primary care provider for the baby. Explain when the STAR Program is effective for pregnant women. If the pregnant woman's Medicaid is certified before the 10th of the month, the enrollment is effective the first day of the certification month (retroed). If the pregnant woman's Medicaid is certified after the 10th of the month, the enrollment is effective the first day of the month following the certification date (prospective).


PCCM Expansion: TIERS automatically establishes an enrollment in PCCM for all mandatory recipients at certification. Enrollments are prospective. (Depends on certification date and state cutoff). Direct recipient to contact PCCM to change PCP for herself and/or newborn.

Note for Pregnant Women: If a pregnant woman has 12 weeks or less remaining in her pregnancy (third trimester), she may choose to remain with her current OB/GYN for the remainder of her pregnancy, delivery, and postpartum checkup, even if the OB/GYN does not participate with the chosen health plan.

  1. Changes:
    STAR/STAR+PLUS recipients can change their primary care provider up to 4 times a year; they can have unlimited changes in health plan (however, there are time restrictions – each health plan change can take 15-45 days). Call the STAR helpline to change the health plan and call the health plan directly to request a primary care provider change. PCCM expansionrecipients need to call the PCCM helpline to change their PCP.

Medicaid Program Knowledge

  • Medicaid pays for you or your child's care when they go to the doctor, if they are in the hospital, if they go to the dentist and if they go to a specialist. It will also pay for prescriptions, shots, transportation to any Medicaid covered service, and for behavioral health services. It also pays for preventive medical and dental checkups for children under age 21 through the THSteps program even when they are not sick.
  • Medicaid only pays providers like doctors, dentists, specialists and hospitals. You should not receive any bills. However, if you receive a bill don't pay it. First call the provider and find out why they did not send the bill to Medicaid. Make sure your provider has the Medicaid ID number needed for billing. If the recipient is on STAR/STAR+PLUS direct them to call their health plan. If they are in PCCM Expansion, direct them to call the PCCM helpline. If they are on fee for service direct them to call the number on the back of the Your Texas Benefits Medicaid ID card for billing questions 1-800-252-8263.

Your Texas Benefits Medicaid ID card-Process

  • Ask the family if they have received their new Your Texas Benefits Medicaid Id card. If not, explain the new card they will receive is good for as long as they are on Medicaid. Describe the Your Texas Benefits Medicaid ID card.
  • STAR Health: The STAR Health logo will be on the top right side of the Your Texas Benefits Medicaid Card. Their STAR or STAR+PLUS health plan will also be listed on the card. Thier STAR or STAR+PLUS logo will not show on the top right side of the Your Texas Benefits Medicaid ID card. PCCM Expansion: PCCM logo will be listed on the top right corner of the Your Texas Benefits Medicaid ID card.
  • Remind the family to take the Your Texas Benefits Medicaid ID card to the doctor, dentist, pharmacy or every time they obtain a Medicaid service.
  • Explain to the family if they do not receive their Your Texas Benefits Medicaid ID card in the next couple of weeks, to contact their local HHSC office to confirm eligibility. Once eligibility is confirmed, they can contact the Your Texas Benefits Medicaid ID card Help Desk to check the status of the card order. Inform them they can also print a copy of their card from the YourTexasBenefits.com website while they wait on their permanent card.

Maintaining Eligibility

  • Follow up with any paper work you receive from the Health and Human Services Commission (also called HHSC). HHSC reviews your case from time to time, usually every 12 months and so it is very important to complete the paperwork to keep your child/children on Medicaid.
  • It is a requirement to receive your health care orientation (we are providing that right now) and for your children to receive their THSteps preventive checkups to avoid having to go to the office for a face to face interview or to be required to return follow-up information at your redetermination.

THSteps Program Knowledge

  • THSteps is Medicaid for people in Texas under age 21. It includes regularly scheduled medical and dental checkups to make sure your children are growing up healthy, as well as when your children are sick. Regular checkups find health problems while they are still small and easily treated.

Checkup Schedule & Components

  • Explain to the family when each child is due for a medical checkup according to their date of birth following the periodicity schedule. Give the family a wallet card, Checkups and a Whole Lot More brochure and the Visits to the Doctor/Dentist brochure if in person.
  • Explain that the children are eligible for a dental checkup beginning age 1 and every 6 months thereafter.
  • Review components of both the medical and dental checkup for each child by age (see attached chart)
  • Remind the family if a medical or dental problem is found during the THSteps checkup and is medically necessary, Medicaid will cover the follow up treatment.
  • Your child/children may receive an excused absence from school for medical and dental appointments

Dental Providers

  • Do you have a dentist who accepts Medicaid?
  • Provide list of at least three providers in the individual's area so they can choose. A list can be mailed upon request. Advise the family to contact the helpline if they want a list immediately.

Medical Providers
PCCM / Traditional Medicaid

  • Have you checked with your PCP to see if he/she will do the THSteps medical checkup? You can receive a THSteps checkup from any THSteps provider if your PCP does not do the checkups. It is important to have a medical home for your child. A medical/dental home is when you have a provider who treats your child regularly, who knows your child's health condition and has the responsibility for keeping your child's medical records and for coordinating medical care. If you family needs help finding a THSteps provider call the THSteps helpline at 1-877-847-8377. It is open 8 a.m. to 8 p.m. Central time. It is a free call.

Managed Care

  • Encourage family to go to PCP for THSteps Checkup if provider does checkup
  • Explain if PCP doesn't do THSteps checkup call Plan for THSteps provider
  • If enrollment into STAR has not processed yet, they can use any Medicaid provider for service until the enrollment is effective.

Scheduling the Appointment

  • If the family has already chosen a THSteps Medical, Dental or Case Management Provider ask if they would like help scheduling an appointment. If they say yes and would like do a three way call with the provider's office, please process if your phone is capable or ask them to call the Customer Care Center for assistance.
  • If they have not yet chosen a provider tell the family we would be happy to help them schedule an appointment when they choose a provider by calling the THSteps helpline at 1-877-847-8377.

Case Management for Children and Pregnant Women (CPW)-see the special services script

Medical Transportation Program (MTP)

  • The Medical Transportation Program provides non-emergency medical transportation (NEMT) services.
  • Explain the Medical Transportation Program is available for all Medicaid-covered health care services to those with full Medicaid (not Qualified Medicare Beneficiary [QMB] or Specified Low-Income Medicare Beneficiary [SLMB]), Children with Special Health Care Needs (CSHCN), and Transportation for Indigent Cancer Patients (TICP), who do not have any other means of transportation.
  • Call at least two business days before the appointment in the same county or adjacent county and five business days before an appointment outside the county adjacent to your residence and be prepared to provide your:
    • name;
    • Medicaid ID number;
    • address;
    • phone number;
    • doctor's name and address;
    • doctor's phone number;
    • date; and
    • time of appointment.

Three Ways to Travel:

  • If you don't have a car and you don't have anyone else to drive you, the Medical Transportation Program will help. This may be by bus tickets or by van.
  • If you have a car, or know someone who can drive you to the appointment, the Medical Transportation Program can pay you or your driver gas reimbursement by the mile.

Call 1-877-MED-TRIP or 1-877-633-8747 (Option 1) to schedule a ride. If you have a complaint or concern, call 1-877-MED-TRIP or 1-877-633-8747 (Option 2).

Children's Health Insurance Program (CHIP)

  • If anyone in household is under age 19 does not have health insurance, explain they may be eligible for some type of state funded health insurance. The may call 1 800-647-6558 to apply for CHIP and Children's Medicaid.

WIC (Women, Infant, and Children's Program)

  • Explain WIC is a supplemental nutrition education program to provide nutritious foods to help women, infants and children improve on their nutrition. If you are receiving Medicaid, you are income eligible for the program, but will have to complete a nutritional screening to receive benefits.
  • If pregnant or a postpartum woman, or a child in household under 5 lives in the household, give the parent the 1-800-942-3678 number to locate their nearest WIC office to them.

Summary

  • Any Questions regarding THSteps or Medicaid?
  • Inform individual that they have received a "Health Care Orientation"
  • Verify individual information, phone number, migrant status, any other children in the household
  • If enrolled, recap enrollment information include PCP and health plan.
  • Follow up questions about having a medical or THSteps appointment or scheduled a medical or THSteps appointment since certification date (on list).
  • Provide toll free number for future assistance. Thank the individual for their time.
  • If in person, provide literature and "Helpful Toll Free Number" handout.

Medical Checkup components include:

Newborn to 2 weeks 2-6 months (every 2 months) 7-12 months (every 3 months) 13 months – 2 years (every 3 months) 3-5 years (once a year) 6-10 years (once a year) (except 7/9 for non-foster) 11-20 years (once a year)
Family and newborn history Family and child health history Family and child health history Family and child health history Family and child health history Family and child health history Family and child health history
Unclothed physical exam Unclothed physical exam Unclothed physical exam Unclothed physical exam Unclothed physical exam Unclothed physical exam Unclothed physical exam
Height, weight and head circumference Height, weight and head circumference Height, weight and head circumference Height, weight and head circumference Height, weight and blood pressure Height, weight and blood pressure Height, weight and blood pressure
Vision and hearing checks Vision and hearing checks Vision and hearing checks Vision and hearing checks Vision and hearing checks Vision and hearing checks Vision and hearing checks
Development progress including response to noise, eye contact Development progress including interest in surroundings, vocalizing, smiling Development progress including feeding self, beginning speech Development progress including speech development and motor skills Development progress including ability to dress self and speech development Developmental progress and mental health screening: school performance, social interaction Developmental progress and mental health screening: school performance, social interaction
Nutrition: how often and how much baby eats Nutrition: how often and how much baby eats Nutrition: eating solids, no bottle in bed Nutrition: weaning and healthy diet Nutrition: healthy diet and physical activities Nutrition: iron rich foods, junk foods Nutrition: healthy diet, physical activities
Blood tests for hereditary diseases Blood tests for hereditary diseases Blood tests or screening for anemia and lead poisoning Blood tests or screening for anemia and lead poisoning Blood tests or screening for anemia and lead poisoning Blood tests or screening for anemia and lead poisoning Blood tests or screening for anemia or other diseases
Shots (immunizations) Shots (immunizations) Shots (immunizations) Shots (immunizations) Shots (immunizations) Shots (immunizations) Shots (immunizations)
Health/ Safety information (sleep position, injury prevention, calling doctor) Health/ Safety information (injury prevention, immunizations, sleep habits) Health/ Safety information (car seats, child proofing home, speech) Health/ Safety information (car seats, water safety, dental care) Health/ Safety information (car safety, second hand smoke, reading) Health/ Safety information (auto safety, bicycle helmets, water safety) Health/ Safety information (car/motorcycle safety, sun exposure, substance abuse)
- - Dental referrals Dental referrals Dental referrals Dental referrals Dental referrals
- - TB Screening TB Screening TB Screening TB Screening TB Screening

Dental Checkup Components include*:

Newborn through 12 months 12 months 13 months through 2 years 3 through 20 years
No dental checkup at this age First dental checkup at one year Dental checkups every six months after the date of the last periodic checkup Dental checkups every six months after the date of the last periodic checkup
- Introduce child to dental checkups Introduce child to dental checkups -
- Check for signs of baby bottle tooth decay Check for signs of baby bottle tooth decay -
- Examination of gums and tooth development Examination of gums and tooth development Examination of gums and tooth development
- Demonstration of tooth cleaning Demonstration of tooth cleaning Demonstration of tooth cleaning
- - Dental treatment if necessary Dental treatment if necessary

 

* Emergency dental services are available at any age (do not require a check on ID)

 

C—1120 IRS Tax Code

Revision 15-4; Effective October 1, 2015

Unauthorized disclosure or unauthorized inspection of an applicant or client’s federal tax information by HHSC staff is punishable by law, including but not limited to:

  • felony charges,
  • imprisonment,
  • fines,
  • employment dismissal, or
  • civil charges.

See United States Code (U.S.C.), Title 26, §7213; 26 U.S.C. §7213A; and 26 U.S.C. §7431 for a complete list of penalties for the unauthorized disclosure or inspection of this information.

 

C—1130 Electronic Benefit Transfer (EBT) Charts and Guides

Revision 15-4; Effective October 1, 2015

 

 

 

C—1131 Advisor Guide for Explaining EBT

Revision 18-1; Effective January 1, 2018

 

TANF and SNAP

Instruct the cardholder to read Form H1185, Important Information About Your Lone Star Card, and to ask questions about any EBT issuance procedures the cardholder does not understand. Advisors must also explain:

  • Procedures for Lone Star Card issuance and PIN issuance/self-selection to access benefits including:
    • primary cardholder and secondary cardholder (including how to establish a secondary cardholder);
    • how access is limited to a person with both the card and the PIN;
    • that there is no charge for using the Lone Star Card for food account purchases; and
    • that to obtain benefits they need to have a card, PIN and available benefits.
  • When applicants will be able to use their initial benefits, if certified, and explain the availability of monthly benefits as specified in Form H1184, Here Is Your Lone Star Card.
  • How and where to use the Lone Star Card including:
    • how to make a purchase (and/or cash withdrawal for TANF), availability of receipts and the need to save EBT receipts to keep track of account balance(s);
    • how to identify stores accepting SNAP/Lone Star Cards and how to ask store personnel if the store provides TANF cash-back services; and
    • the TANF cash-back policy. See B-239.1, Advisor Interview Requirements for Client Training.
  • Card/PIN security including:
    • how to keep their benefits secure;
    • what to do if a card is lost or stolen or the PIN is compromised; and
    • that HHSC will not replace benefits used before a card is reported lost or stolen to the Lone Star Help Desk.
  • The dormant account policy. If the cardholder does not access the EBT account for a limited number of consecutive months, their benefits become dormant. They may still access benefits in their EBT account. See B-361, Dormant Account Policy.
  • Procedures when moving out of Texas including the:
    • use of the Lone Star Card to access:
      • TANF at retailers in other states; or
      • SNAP benefits at retailers; and
    • recommendation to withdraw all available cash benefits from the cash account before leaving the state.

      Note: HHSC may mail a benefit conversion warrant (full month's TANF benefit only) to the household's new address if the:

      • cardholder cannot find a retailer that accepts the Lone Star Card; and
      • household moved out of state on or after the first of the month but before accessing that month's TANF benefits. See B-331, Cancelling Benefits in EBT Accounts.

 

C—1132 Issuance Staff Guide for EBT Issuance and Client Training

Revision 18-1; Effective January 1, 2018

 

TANF and SNAP

After receiving Form H1172, EBT Card, PIN and Data Entry Request, authorizing an initial Lone Star Card and PIN to the primary cardholder, take the following actions:

  • Issue and briefly explain the:
    • Lone Star Card;
    • card sleeve;
    • PIN packet, if applicable;
    • Form H1184, Here Is Your Lone Star Card; and
    • second cardholder form.
  • If giving the Lone Star Card to someone other than the primary cardholder, then:
    • explain the use of each item to the person receiving the card;
    • place a registration sticker on the card; and
    • if applicable, request that the vendor mail a PIN packet to the primary cardholder.
  • If mailing the Lone Star Card to the primary cardholder, then select vendor mail out.
  • Explain:
    • the importance of saving the last receipt for the current account balance(s);
    • card registration, if required;
    • the requirement for the primary cardholder to sign the back of the card;
    • how to protect the card and what to do if it is lost or stolen; and
    • how to protect the PIN and what to do if it is compromised.
  • Advise the individual to call the toll-free Lone Star Help Desk (800-777-7EBT or 800-777-7328) if they have problems accessing benefits or additional questions.

 

C—1140 TANF and SNAP Overpayment Determination Chart

Revision 01-7; Effective October 1, 2001

 

 

 

C—1141 Timely Reported

Revision 13-3; Effective July 1, 2013

 

TANF and SNAP

When the individual reports a change timely (i.e., individual reported within 10 days of knowing of the change), use B-600, Changes, B-752.1.2, Errors After Certification, and the following chart to determine the first month of overpayment.

If the household reported the change... then the first month of potential overpayment is...
January 1-8
January 9-31
February
March
February 1-5
February 6-28 (or 29th)
March
April
March 1-8
March 9-31
April
May
April 1-7
April 8-30
May
June
May 1-8
May 9-31
June
July
June 1-7
June 8-30
July
August
July 1-8
July 9-31
August
September
August 1-8
August 9-31
September
October
September 1-7
September 8-30
October
November
October 1-8
October 9-31
November
December
November 1-7
November 8-30
December
January
December 1-8
December 9-31
January
February

 

Note: The first month of overpayment can be no later than two months from the month the change occurred.

 

C—1142 Untimely Reported

Revision 13-3; Effective July 1, 2013

 

TANF and SNAP

When the individual fails to report a change timely (i.e., does not report a change later discovered by HHSC or untimely reports a change), use B-600, Changes, B-752.1.2, Errors After Certification, and the following chart to determine the first month of overpayment.

If the change occurred... then the first month of potential overpayment is...
January 1-31 March
February 1-28 (29) April
March 1-31 May
April 1-30 June
May 1-31 July
June 1-30 August
July 1-31 September
August 1-31 October
September 1-30 November
October 1-31 December
November 1-30 January
December 1-31 February

 

Note: The first month of overpayment can be no later than two months from the month the change occurred.

 

C—1150 Type Programs (TP) and Type Assistance (TA)

Revision 18-1; Effective January 1, 2018

 

SNAP, TANF and Medical Programs/Assistance

 

SNAP

Code

Description

Long Description

TA 51 SNAP-CAP/FS-CAP Supplemental Nutrition Assistance Program Combined Application Project
TA 52 SNAP-SSI/FS-SSI Supplemental Nutrition Assistance Program Supplemental Security Income
TP 06 SNAP (PA)/FS-PA Supplemental Nutrition Assistance Program Public Assistance
TP 09 SNAP/FS-NPA Supplemental Nutrition Assistance Program

 

TANF

Code

Description

Long Description

TP 01 TANF Basic Cash assistance for caretakers and deprived children with income below TANF recognizable needs
TP 60 TANF Grandparent Payment One-time payment for grandparent who is caretaker of their TANF-certified grandchild
TP 61 TANF State Program Cash assistance for two-parent household with income below TANF recognizable needs
TP 71 OTTANF – 1 Adult One-Time TANF (OTTANF) payment for households with one parent
TP 72 OTTANF – 2 Parents OTTANF payment for households with two parents

 

Medical Programs/Assistance — Texas Works

Code

Description

Long Description

TA 31 MA – Parents and Caretaker Relatives – Emergency Medicaid for an emergency condition for parents and caretaker relatives who do not meet alien status requirements and are caring for a dependent child who receives Medicaid
TA 41 Health Care – Healthy Texas Women Healthy Texas Women (HTW) for women age 15–44 with income at or below the applicable income limit
TA 66 MA – MBCC – Presumptive Medicaid for Breast and Cervical Cancer – Presumptive
TA 67 MA – MBCC Medicaid for Breast and Cervical Cancer
TA 74 MA – Children Under 1 Presumptive Short-term Medicaid for children under age 1 with income at or below the applicable income limit
TA 75 MA – Children 1–5 Presumptive Short-term Medicaid for children ages 1–5 with income at or below the applicable income limit
TA 76 MA – Children 6–18 Presumptive Short-term Medicaid for children ages 6–18 with income at or below the applicable income limit
TA 77 Health Care – FFCHE Health Care for Former Foster Care in Higher Education with income at or below the applicable income limit
TA 82 MA – Former Foster Care Children Medicaid for former foster care children ages 18–25
TA 83 MA – FFCC Presumptive Short-term Medicaid for former foster care children ages 18–25
TA 84 CI – CHIP The Children’s Health Insurance Program (CHIP) is health care coverage for children under age 19 who are ineligible for Medicaid due to income and who have income at or below the applicable income limit
TA 85 CI – CHIP perinatal CHIP perinatal is health care coverage for unborn children whose mother is ineligible for Medicaid or CHIP due to income and/or immigration status and whose income is at or below the applicable income limit
TA 86 MA – Parents and Caretaker Relatives Presumptive Short-term Medicaid for parents and caretaker relatives caring for a dependent child
TP 02 MA – Refugee

Refugee Medical Assistance (RMA) for refugees who are ineligible for any other type of Medicaid and have income at or below the applicable income limit

Note: Effective Feb. 1, 2017, HHSC no longer adminsters RMA.

TP 07 MA – Earnings Transitional Twelve months of transitional Medicaid resulting from an increase in earnings
TP 08 MA – Parents and Caretaker Relatives Medicaid for parents and caretaker relatives caring for a dependent child with income at or below the applicable income limit
TP 20 MA Alimony/Spousal Support Transitional Up to four months of post Medicaid resulting from an increase in alimony/spousal support
TP 32 MA – MN w/Spend Down – Emergency Medicaid for an emergency condition for children or pregnant women who do not meet alien status requirements and who are ineligible for any other type of Medicaid, but who have medical expenses that spend down their income to below the Medically Needy Income Limit (MNIL)
TP 33 MA – Children 1–5 – Emergency Medicaid for an emergency condition for children age 1–5 who do not meet alien status requirements and who have income at or below the applicable income limit
TP 34 MA – Children 6–18 – Emergency Medicaid for an emergency condition for children age 6–18 who do not meet alien status requirements and who have income at or below the applicable income limit
TP 35 MA – Children Under 1 – Emergency Medicaid for an emergency condition for children under age 1 who do not meet alien status requirements and who have income at or below the applicable income limit
TP 36 MA – Pregnant Women – Emergency Medicaid for an emergency condition for pregnant women who do not meet alien status requirements and who have income at or below the applicable income limit
TP 40 MA – Pregnant Women Medicaid for pregnant woman with income at or below the applicable income limit
TP 42 MA – Pregnant Women Presumptive Short-term Medicaid for pregnant women with income at or below the applicable income limit
TP 43 MA – Children Under 1 Medicaid for children under age 1 with income at or below the applicable income limit
TP 44 MA – Children 6–18 Medicaid for children age 6–18 with income at or below the applicable income limit
TP 45 MA – Newborn Children Medicaid for children through age 1 who are born to a Medicaid-eligible mother
TP 48 MA – Children 1–5 Medicaid for children age 1–5 with income at or below the applicable income limit
TP 56 MA – MN w/Spend Down Medicaid for children or pregnant women who are ineligible for any other type of Medicaid, but who have medical expenses that spend down their income to below the MNIL
TP 70 Medicaid for the Transitioning Foster Care Youth Medicaid for Transitioning Foster Care Youth individuals with income at or below the applicable income limit
TPAL MA – Historical FMA – Emergency N/A
TPDE MA – Deceased Prior Medical Medicaid for a deceased individual
TPPM MA/ME – Historical Prior Medical Three months of prior Medicaid – not currently eligible

 

Medical Programs/Assistance — Texas Department of Family and Protective Services

Code

Description

Long Description

TP 52 MA – State Foster Care – A Medicaid
TP 53 MA – State Foster Care – B Medicaid
TP 54 MA – State Foster Care – 32 Medicaid
TP 57 MA – State Foster Care – D Medicaid
TP 58 MA – State Foster Care – JPC Medicaid
TA 78 PCA Medicaid – Federal Match – No Cash Permanency Care Assistance (PCA) Medicaid – Federal Match – No Cash
TA 79 PCA Medicaid – No Federal Match – No Cash PCA Medicaid – No Federal Match – No Cash
TA 80 PCA Medicaid – Federal Match – With Cash PCA Medicaid – Federal Match – With Cash
TA 81 PCA Medicaid – No Federal Match – With Cash PCA Medicaid – No Federal Match – With Cash
TP 88 MA – Non-AFDC Foster Care – JPC Medicaid
TP 90 MA – State Foster Care Medicaid
TP 91 Adoption Assistance – Federal Match – No Cash Adoption Assistance – Federal Match – No Cash
TP 92 Adoption Assistance – Federal Match – With Cash Adoption Assistance – Federal Match – With Cash
TP 93 Foster Care – Federal Match – No Cash Foster Care – Federal Match – No Cash
TP 94 Foster Care – Federal Match – With Cash Foster Care – Federal Match – With Cash
TP 95 Adoption Assistance – No Federal Match – No Cash Adoption Assistance – No Federal Match – No Cash
TP 96 Adoption Assistance – No Federal Match – With Cash Adoption Assistance – No Federal Match – With Cash
TP 97 Foster Care – No Federal Match – No Cash Foster Care – No Federal Match – No Cash
TP 98 Foster Care – No Federal Match – With Cash Foster Care – No Federal Match – With Cash
TP 99 MA – Non-AFDC Foster Care Medicaid
TPAS MA – Historical Adoption Subsidy Medicaid

 

Medical Programs/Assistance — Medicaid for the Elderly and People with Disabilities

Code

Description

Long Description

TA 01 ME – Interim SSI Denied Child Medicaid (processed by SSA)
TA 02 ME – SSI Waivers SSI Recipient Waivers
TA 03 ME – Manual SSI Waivers Manual SSI Waivers
TA 04 ME – Manual SSI State Group Home Manual SSI Recipient State Community-based Group Homes
TA 05 ME – Manual SSI Non-State Group Home Manual SSI Recipient Non-State Community-based Group Homes
TA 06 ME – Manual SSI Nursing Facility Medicaid for Nursing Facility Resident
TA 07 ME – Manual SSI State Hospital Medicaid for State Hospital Resident
TA 08 ME – SSI State Group Home SSI Recipient State Community Based Group Home
TA 09 ME – Manual SSI State Supported Living Center Medicaid for State Supported Living Center Resident
TA 10 ME – Waivers Medicaid
TA 12 ME – State Group Home Medicaid for ICF/IID Resident
TA 15 ME – Rider 51 – Non-State Group Home  
TA 16 ME – Rider 51 – State Supported Living Center Medicaid for State Supported Living Center Resident
TA 17 ME – Rider 51 – Nursing Facility Medicaid for Nursing Facility Resident
TA 18 ME – Grandfathered LTC N/A
TA 21 ME – SSI Chest Hospital Medicaid for Chest Hospital Patient
TA 22 ME – Manual SSI Manually certified SSI — processed by SSA
TA 24 ME – Rider 51 – State Group Home  
TA 25 ME – Rider 51 – State Hospital  
TA 26 ME – SSI Non-State Group Home SSI Non-State Community-based Group Homes
TA 27 ME – Prior Medicaid Institutional/Waiver Prior Medicaid for individual applying for Institutional or Waiver Medicaid
TA 88 ME – Medicaid Buy-In for Children Medicaid benefits to eligible children with disabilities who are not eligible for Supplemental Security Income (SSI) for reasons other than disability. Individuals must pay a share of the Medicaid premium
TP 03 ME – Pickle RSDI COLA Disregard Programs — considered eligible based on the 1977 Pickle Amendment
TP 10 ME – State Supported Living Center Medicaid for State Support Living Center Resident
TP 11 ME – SSI Prior SSI, two or three months prior, as appropriate
TP 12 ME – Temp Manual SSI Manually certified SSI (processed by SSA)
TP 13 ME – SSI SSI (processed by SSA)
TP 14 ME – Community Attendant Community Attendant Services
TP 15 ME – Non-State Group Home Medicaid For ICF/IID Resident
TP 16 ME – State Hospital Medicaid for ICF/IID Resident
TP 17 ME – Nursing Facility Medicaid for State Hospital Resident
TP 18 ME – Disabled Adult Child Adult children (at least age 18) who have a disability and who were denied SSI due to an entitlement to or an increase in their Social Security Disabled Adult Child benefits and who are eligible for Medicaid to ensure continued coverage
TP 21 ME – Disabled Widow(er) Widows/widowers or surviving divorced spouses age 50–65 who have a disability and who are ineligible for Medicare and were denied SSI due to an increase in their RSDI widow/widower benefits. They are eligible for Medicaid under TP 21 until they reach age 65 or become eligible for Medicare, whichever occurs first
TP 22 ME – Early Aged Widow(er) Early age widows/widowers or surviving divorced spouses age 50–65 who are ineligible for Medicare and who were denied SSI due to an increase in their RSDI widow/widower benefits. They are eligible for Medicaid under TP 22 until they reach age 65 or become eligible for Medicare, whichever occurs first
TP 23 MC – SLMB Medicare Savings Program — Specified Low-Income Medicare Benefits
TP 24 MC – QMB Medicare Savings Program — Qualified Medicare Beneficiary
TP 25 MC – QDWI Qualified Disabled and Working Individuals — A special Medicare savings program that pays Part A Medicare premiums for certain working individuals under age 65 who have a disability and are no longer eligible for free Medicare Part A because of earnings
TP 26 MC – QI 1 Medicare savings program — Qualified individuals
TP 27 MC – QI 2 Medicare savings program — Qualified individuals (not an active program)
TP 30 ME – A and D Emergency Emergency Medicaid for a nonqualified alien
TP 38 ME – SSI Nursing Facility Medicaid for Nursing Facility Resident
TP 39 ME – SSI State Hospital Medicaid for State Hospital Resident
TP 41 ME – Skilled Nursing Care Skilled Nursing Facility Co-payments
TP 46 ME – SSI State Supported Living Center Medicaid for State Supported Living Center Residents
TP 50 ME – Rider 51J Medicaid for Nursing Facility Resident
TP 51 ME – Rider 51J Waivers Medicaid
TP 87 ME – Medicaid Buy In Working individuals with disabilities who pay a share of the Medicaid premium to be eligible for Medicaid